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FOR OFFICE USE: <br /> 1 APPLICATION FOR SANITATION PERMIT <br /> = aZ- d Pefmit No. <br /> h r, <br /> ��;, ------------- {Complete in Triplicate} � `} <br /> ----------_-------_-------------------------------_------- This Date Issued Permit Expires i Year From Date Issued t <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein i <br /> described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION .__.-cry. [` - =atm L�----------------------------------------- ----------- --.--CENSUS TRACT -------------------------- <br /> Owner's Name ---�SS�C-�`` �J- "`1"i ,�./...------------------------ -------------------------- ------Phone -------------------------- <br /> Address _____. _�_ _- <br /> �t�------G'ls � �fi'_��_�------------ City b�12-14— _"?VV _ ---------------------------•------ <br /> Contractor's Name ______ __. <br /> v�T�? -=� aT -----------------------------License #140_ cR _ Phone <br /> Installation will serve: Residence[Apartment House❑ Commercial ❑Trailer Court ;❑ <br /> .,i Motel ❑Other ------------------------------------------- <br /> Number of living units:_L-Z____ Number of bedrooms ______Garbage Grinder -Ale- Lot Size aa-"ex__ / .._._...... <br /> Water Supply Public System and name _-L-Q._ -- - _ --------------------------------------------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand [] Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam j] <br /> Hardpan ❑ Adobe Fill Material __________ If yes, type ____________________ <br /> (Plot plan, showing size of lot, location of system.in relation to wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK'[ J Size------------------------------------------------ Liquid Depth ------------- <br /> Capacity ---------------------------------------- Type ----=--------------- Material--------------------._ No. Compartments <br /> 'Distarice to nearest: Well ------------------------------------Foundation --------------------- Prop. Line -------------:-_------ <br /> LEACHING LINE,Z4 [ ] No ,of.Lines r___l -- ------ Length of egch line---------------------------- Total Length -----------.--------.------- <br /> 'D' Box ------------ Type Filter Material --------------------Depth Filter Material -------------------------------------------- <br /> Distance to nearest: Well ________________________ Foundation ------------------------ Property Line ------------------------- <br /> SEEPAGE PIT Depth -------------------- Diameter _______________ Number ---------------------------- Rock Filled Yes ❑ No ID <br /> �Water Table Depth ------------------------------------------------Rock Size -----------------------------+ <br /> Distance to nearest. Well --------------------------------------- Foundation -------------------- Prop. Line -------------- ....... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# _-----------------_------------------ _____ Date -_-_---__--_______________________} <br /> Septic Tank (Specify Requirements) -------------------------------------------------------------------------- --- ------------------ F- --- ------ --------- ' <br /> Com- �-=Q.� ',_ � <br /> Disposal Field (specify Requirements) ----�- -- --- _ _--- 1 - ----__-A - ------- -5%iP------ <br /> - <br /> �.G�G'� - --- j '------------ 7�-------- , <br /> --------------- ---------- -------------------------------------------- ------------------------------------------------------------------ - <br /> - --------------------------------------------------------- <br /> ' (Draw existing and required addition on reverse side) I <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquini. <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin local Health District. Home owner or licen- <br /> sed agents signature certifies the following: <br /> "I certify thatinthe performance of the work for which this permit is issued, I shall not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed --------------------- ----------------- - ------ --- ------------------- Owner .. <br /> BY ) Title �� <br /> - - - ---------------- <br /> ----------------------------- <br /> (If a than owner <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -------------------------------------------------------------- DATE ---- f)�=-,0�------------ , •.� <br /> BUILDING PERMIT ISSUED ---------- DATE ------------------------------------------- <br /> ADDITIONAL COMMENTS �f - = P % --- <br /> -----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------=------------ --- <br /> ------------------------------------------ <br /> ------------------------------------------------------------- <br /> ------------------------------------ ------------------------------------ <br /> -------------- --------- ----- ---- --- <br /> ---- ------------------------------------ <br /> Final, Inspection by --------------------------------------------------- <br /> ------- ------ ------------------------------------------------------ - ---------------------------Date ----47.2--"'---� ' <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />